Question

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

Answer 1

Correct Answers:

Focus on small achievable tasks, not taxing problems.

Rationale :

🧠Depressed clients often experience feelings of helplessness and fatigue, making large or complex tasks overwhelming.

💡By focusing on small achievable goals, the client can experience success and begin to rebuild self-confidence.

💁‍♂️This approach supports behavioral activation, which is a therapeutic technique used to break the cycle of inactivity and low mood.

🧩It also fosters improved functioning by gradually increasing engagement in daily responsibilities without creating additional stress.

📌Core Message

Encouraging small, manageable tasks helps depressed clients regain function and self-efficacy.

Answer 2

Correct Answers:

Returns to her previous level of functioning.

Rationale :

🧠The primary goal of acute psychiatric hospitalization is to stabilize the client and restore pre-crisis functioning.

🧯This includes addressing safety, emotional regulation, and supporting coping mechanisms that allow for discharge and community reintegration.

💬Identifying personal traits or discussing future relationships may support long-term recovery, but do not address the immediate crisis.

🧭Helping the client return to their prior level of functioning lays the foundation for long-term therapeutic goals later.

📌Core Message

The first goal after a crisis is to help the client return to their baseline level of functioning.

Answer 3

Correct Answers:

Spend time sitting in silence with the client.

Rationale :

🧘‍♀️Depressed clients may have psychomotor retardation and take longer to respond, making silence a therapeutic presence.

🕰️Spending quiet time without pressure demonstrates acceptance and fosters trust in the therapeutic relationship.

💬Pushing for answers or discussions too early may increase anxiety or withdrawal.

🌱This approach allows the nurse to provide nonverbal support, which is crucial in early stages of depression care.

📌Core Message

In depression, therapeutic silence builds trust and encourages communication.

Answer 4

Correct Answers:

Explain that opioid receptor response reduces with continued use.

Rationale :

🧠The need for increased dosage reflects the development of tolerance, a physiological effect of long-term opioid use.

🔁Tolerance occurs when the opioid receptors become less responsive, requiring more of the drug for the same effect.

📘Educating the client about this mechanism helps them understand the difference between dependence and addiction.

💬This explanation supports nonjudgmental communication and opens the door for future discussions on pain management alternatives.

📌Core Message

Opioid tolerance results from decreased receptor sensitivity and requires education for safe use.

Answer 5

Correct Answers:

The other nurses and I are here to help you get better.

Rationale :

👥Clients with borderline personality disorder often use splitting as a defense mechanism, labeling others as “all good” or “all bad.”

⚖️A neutral, consistent response helps avoid reinforcing this distorted perception and maintains professional boundaries.

🧘‍♂️Validating the care of the entire team rather than individualizing praise promotes team consistency and therapeutic alliance.

💬This response shifts focus from favoritism to the client’s overall recovery, which is the primary goal.

📌Core Message

Use neutral, team-oriented responses to manage splitting behavior effectively.

Answer 6

Correct Answers:

Provide referrals from the physician for mental health services
Follow up with the client in a few weeks
Document verbatim statements about the abuse

Rationale :

🧾Providing referrals for mental health services helps address trauma and long-term support needs.

📫Mailing information discreetly ensures confidentiality and safety, especially if the client lives with the abuser.

📝Documenting verbatim statements provides accurate legal and clinical evidence, essential for follow-up or legal proceedings.

🚨Calling the police is not always mandated unless there is immediate danger or the client is a minor, so discretion is key.

📌Core Message

Provide safe referrals, respect privacy, and ensure accurate documentation in abuse cases.

Answer 7

Correct Answers:

Sleeps at least six hours a night.

Rationale :

🛌Poor sleep is both a symptom and a contributing factor to depression and must be addressed early in treatment.

🌙Improving sleep can reduce emotional lability and increase coping capacity, leading to better adherence to therapy.

💊Antidepressants may take several weeks to improve mood, but sleep often improves earlier and indicates treatment response.

🩺This goal is measurable and realistic, allowing clinicians to monitor early signs of progress.

📌Core Message

Improved sleep is a key early sign of progress in antidepressant therapy.

Answer 8

Correct Answers:

Current vital signs.

Rationale :

🌡️Neuroleptic malignant syndrome (NMS) is a medical emergency often marked by hyperthermia, tachycardia, and altered mental status.

📈Monitoring vital signs can help detect early warning signs and prevent progression of this life-threatening reaction.

🧬Although labs like WBC may rise in NMS, they are not as immediate or sensitive as clinical assessment.

👩‍⚕️Frequent vital checks allow the nurse to act quickly if fever or instability is present in the client on antipsychotics.

📌Core Message

Checking vital signs helps detect early NMS symptoms in clients on antipsychotics.

Answer 9

Correct Answers:

Attempt to ask the client simple questions.

Rationale :

🧠Clients who are guarded or suspicious may be experiencing paranoia or psychotic features and need gradual engagement.

💁‍♂️Simple, direct questions reduce anxiety and may build trust in the nurse-client relationship.

🚫Avoiding interaction or postponing the interview could reinforce withdrawal or mistrust.

🧩Engaging gently with short questions encourages the client to share and facilitates rapport building.

📌Core Message

Use simple, non-threatening communication to engage guarded clients and build trust.

Answer 10

Correct Answers:

Nausea and vomiting

Rationale :

🤢Nausea and vomiting may indicate lithium toxicity, especially when occurring with a regular dosing schedule.

💊Lithium has a narrow therapeutic index, so even small increases in serum levels can cause serious effects.

📘Common early signs of toxicity include gastrointestinal symptoms, followed by tremors, confusion, or ataxia.

🧠Prompt recognition and reporting of these symptoms are critical to prevent neurotoxicity and renal impairment.

📌Core Message

Nausea and vomiting may signal lithium toxicity and require immediate provider notification.

1 :
A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

2 :
A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?

3 :
When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

4 :
A client reports needing to increase opioid dosage to achieve the original level of pain relief. Which action should the nurse take?

5 :
A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response should the nurse provide to this client?

6 :
Following the visit, what are appropriate actions for the nurse? Select all that apply.

7 :
An antidepressant medication is prescribed for a client who reports sleeping only four hours in the past two days and a weight loss of nine pounds within the last month. Which client goal is most important to achieve within the first three days of treatment?

8 :
A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

9 :
A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

10 :
The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

1 : A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

2 : A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?

3 : When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

4 : A client reports needing to increase opioid dosage to achieve the original level of pain relief. Which action should the nurse take?

5 : A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response should the nurse provide to this client?

6 : Following the visit, what are appropriate actions for the nurse? Select all that apply.

7 : An antidepressant medication is prescribed for a client who reports sleeping only four hours in the past two days and a weight loss of nine pounds within the last month. Which client goal is most important to achieve within the first three days of treatment?

8 : A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

9 : A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

10 : The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

1 :
A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

2 :
A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?

3 :
When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

4 :
A client reports needing to increase opioid dosage to achieve the original level of pain relief. Which action should the nurse take?

5 :
A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response should the nurse provide to this client?

6 :
Following the visit, what are appropriate actions for the nurse? Select all that apply.

7 :
An antidepressant medication is prescribed for a client who reports sleeping only four hours in the past two days and a weight loss of nine pounds within the last month. Which client goal is most important to achieve within the first three days of treatment?

8 :
A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

9 :
A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

10 :
The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?